Does my patient with a serum monoclonal spike have multiple myeloma?

Efficacy and Safety of Anti-CD38 Monoclonal Antibodies in Patients with Relapsed or Refractory Multiple Myeloma: A Meta-Analysis of Randomized Clinical Trials

The benefit of associating anti-CD38 monoclonal antibodies to proteasome inhibitor (PI)/immunomodulatory agent (IA) and dexamethasone in the treatment of patients with relapsed or refractory multiple myeloma (MM) remains unclear. PubMed, Embase, and Cochrane Library databases were searched for randomized controlled trials that investigated the addition of anti-CD38 monoclonal antibodies to a therapy composed of PI/IA and dexamethasone versus PI/IA and dexamethasone alone for treating relapsed or refractory MM. Hazard ratios (HRs) or risk ratios (RRs) were computed for binary endpoints, with 95% confidence intervals (CIs). Six studies comprising 2191 patients were included. Anti-CD38 monoclonal antibody significantly improved progression-free survival (HR 0.52; 95% CI 0.43-0.61; p < 0.001) and overall survival (HR 0.72; 95% CI 0.63-0.83; p < 0.001). There was a significant increase in hematological adverse events, such as neutropenia (RR 1.41; 95% CI 1.26-1.58; p < 0.01) and thrombocytopenia (RR 1.14; 95% CI 1.02-1.27; p = 0.02), in the group treated with anti-CD38 monoclonal antibody. Also, there was a significant increase in non-hematological adverse events, such as dyspnea (RR 1.72; 95% CI 1.38-2.13; p < 0.01) and pneumonia (RR 1.34; 95% CI 1.13-1.59; p < 0.01), in the group treated with anti-CD38 monoclonal antibody. In conclusion, the incorporation of an anti-CD38 monoclonal antibody demonstrated a promising prospect for reshaping the established MM treatment paradigms.

The Association of Agent Orange (AO) Exposure with Monoclonal Gammopathy of Undetermined Significance (MGUS) to Multiple Myeloma (MM) Progression: A Population-based Study of Vietnam War Era Veterans

Background

Herbicide and pesticide exposure (e.g., agent orange [AO]) is associated with an increased risk of multiple myeloma (MM) due to the contaminant, 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD). Monoclonal gammopathy of undetermined significance (MGUS) is the precursor state to MM; however, not all patients with MGUS progress to MM. It is unclear whether AO exposure increases the risk of progression of MGUS to MM.

Purpose

We aimed to determine the association between AO exposure and progression to MM in a nation-wide study of U.S. Veterans with MGUS.

Patients and Methods

This is a population-based cohort study of Vietnam Era Veterans diagnosed with MGUS. A natural language processing (NLP) algorithm was used to confirm MGUS and progression to MM. The association between AO and progression was analyzed using multivariable Fine-Gray subdistribution hazard model with death as a competing event. Veterans who served during the Vietnam War Era from 1/9/1962-5/7/1975 and were diagnosed with MGUS between 10/1/1999-12/31/2021 were included. We excluded patients with missing BMI values, progression within 1 year after MGUS diagnosis date, non-IgG or IgA MGUS, or birth years outside of the range of the AO exposed group, and race other than Black and White. AO exposure and service during 1/9/1962-;5/7/1975 and stratified according to TCDD exposure levels by three time periods: 1/9/1962-11/30/1965 (high), 12/1/1965-12/31/1970 (medium), or 1/1/1971-5/7/1975 (low). The association between AO and progression was analyzed using multivariable Fine-Gray subdistribution hazard model with death as a competing event.

Results

We identified 10,847 Veterans with MGUS, of whom 7,996 had AO exposure. Overall, 7.4% of MGUS patients progressed to MM over a median follow-up of 5.2 years. In multivariable analysis, AO exposure from 1/9/1962-11/30/1965, high TCDD exposure, was associated with an increased risk of progression (adjusted hazard ratio 1.48; 95% confidence interval 1.02-2.16), compared to Veterans with no exposure.

Conclusions

In patients with MGUS, the high Agent Orange exposure time period is associated with a 48% increased risk of progression to multiple myeloma. This suggests that patients with MGUS and prior Agent Orange exposure or occupational exposure to TCDD (eg. Agricultural workers) may require thorough screening for plasma cell dyscrasias.

Machine Learning Approach for Rapid, Accurate Point-of-Care Prediction of M-Spike Values in Multiple Myeloma

PURPOSE

The gold standard for monitoring response status in patients with multiple myeloma (MM) is serum and urine protein electrophoresis which quantify M-spike proteins; however, the turnaround time for results is 3-7 days which delays treatment decisions. We hypothesized that machine learning (ML) could integrate readily available clinical and laboratory data to rapidly and accurately predict patient M-spike values.

METHODS

A retrospective chart review was performed using the deidentified, electronic medical records of 171 patients with MM.

RESULTS

Random forest (RF) analysis identified the weighted value of each independent variable (N = 43) integrated into the ML algorithm. Pearson and Spearman coefficients indicated that the ML-predicted M-spike values correlated highly with laboratory-measured serum protein electrophoresis values. Feature selected RF modeling revealed that only two variables-the first lagged M-spike and serum total protein-accurately predicted the M-spike.

CONCLUSION

Taken together, our results demonstrate the feasibility and prognostic potential of ML tools that integrate electronic data to longitudinally monitor disease burden. ML tools support the seamless, secure exchange of patient information to expedite and personalize clinical decision making and overcome geographic, financial, and social barriers that currently limit the access of underserved populations to cancer care specialists so that the benefits of medical progress are not limited to selected groups.

Far and Few Between: Early Onset Multiple Myeloma in a 26-Year-Old Female

Multiple myeloma (MM), a common hematologic malignancy, is predominantly a disease of old age with a median age at diagnosis hovering around 70 years. Medical literature remains largely bereft of reports of the ailment in young female patients. We chronicle the case of a 26-year-old female patient who presented with a history of fever, weight loss, constipation, frequent infections, and back and chest pain. Laboratory workup divulged underlying anemia, renal impairment, increased calcium, and significant urinary proteins, insinuating a diagnosis of MM. Subsequent bone marrow examination confirmed a diagnosis of MM. Following treatment with a concoction of dexamethasone, cyclophosphamide and bortezomib, the patient improved rapidly, and her clinical symptoms abated. This article further accentuates the need for physicians to be cognizant of the possibility of early-onset MM in unusually young patients.

High levels of peripheral blood circulating plasma cells as a specific risk factor for progression of smoldering multiple myeloma

Smoldering multiple myeloma (SMM) carries a 50% risk of progression to multiple myeloma (MM) or related malignancy within the first 5 years following diagnosis. The goal of this study was to determine if high levels of circulating plasma cells (PCs) are predictive of SMM transformation within the first 2–3 years from diagnosis. Ninety-one patients diagnosed with SMM at Mayo Clinic from January 1994 through January 2007 who had testing for circulating PCs using an immunofluorescent assay and adequate follow up to ascertain disease progression, were studied. High level of circulating PCs was defined as absolute peripheral blood PCs >5000 ×10⁶/L and/or > 5% cytoplasmic immunoglobulin (Ig) positive PCs per 100 peripheral blood mononuclear cells. Patients with high circulating PCs (14 of 91 patients, 15%) were significantly more likely to progress to active disease within 2 years compared with patients without high circulating PCs, 71% versus 25%, respectively, P=0.001. Corresponding rates for progression within 3 years were 86% versus 35%, respectively, P<0.001. Overall survival (OS) after both SMM diagnosis and MM diagnosis was also significantly different. High levels of circulating PCs identify SMM patients with an elevated risk of progression within the first 2 to 3 years following diagnosis.